The problem is political. Is the solution technical?

The world is becoming increasingly urban, with over half of the world’s total population now residing in cities. While urban areas offer many economic and livelihood opportunities, they are increasingly characterised by growing inequality. In South Africa, both former homelands and peri-urban areas have been severely neglected in terms of health care and services, resulting in very poor-quality care and extreme discrepancies between rural and urban health statistics. Yet, there is recognition of the need to address peri-urban sexual and reproductive health (SRH) in South Africa.

South African adolescents experience very high levels of pregnancy, due to uneven gender relations, limited comprehensive sexuality education, and poor access to sexual and reproductive health and rights (SRHR) services, including quality contraception options. Poverty and place of residence strongly affect outcomes of adolescent sexual health in South Africa. While it is recognised that women and girls living in low-income residential areas are negatively affected in relation to many aspects of health, including SRHR, very little information is available on health within peri-urban cities and on the interconnections between poverty, place and health. Given this, we set out to understand how ICTs in general, and mHealth in particular, might provide new ways of addressing adolescent sexuality, reproductive health and place in South Africa.

Mobile phones are ubiquitous in South Africa, including in rural, peri-urban and slum contexts. However, investment in infrastructure tends to be in middle class areas where those inhabiting the spaces pay for use, and South Africa is renowned for its high data costs. By contrast, peri-urban and township areas suffer from inadequate access to services, including poor network coverage, weak satellite signals, insufficient bandwidth and limited voice capacity due to congestion and demand. As high unemployment causes a lack of security, women do not carry mobile phones for fear of being attacked and robbed. In some instances women share mobile phones. Rural areas are plagued by uneven conditions of access: female-headed households have poor access to mobile phones, poor satellite reception, no broadband, high data costs, lack of infrastructure as well as health, education and transport inequalities. In general, women and adolescent girls also have less time to access ICTs due to the gendered division of labour and additional domestic burdens. It is also difficult, and often unsafe, to access internet cafes and other public places where ICTs might be freely available. Inequality in ICT access thus maps the pattern of apartheid inequality.

There are also constraints in terms of electricity, language, cost and design - as one responded said, ‘Space is not an issue, rather it is cost’. Patterns of inequality cannot be addressed simply through access. Special policy measures are needed to support infrastructural and other developments in rural areas, inner-city slums and peri-urban areas, but if left to market forces, these areas will remain under-resourced. Yet, as no such policy prescriptions exist, most technical interventions make no attempt to deal with this. For example, although the National Department of Health (NDOH) is aware of the challenges of rural and peri-urban health for women and adolescent girls, MomConnect – its new national Maternal and Child Health programme – does not address high-risk HIV-pregnancies in peri-urban areas, or offer ways of ensuring transport and places for safe delivery in rural areas. It was, as one member of the task force informed us, ‘too complicated to add any nuance at this stage’. Thus MomConnect deals with questions of space only in terms of connectivity. Implementers working with the NDOH argue that ‘technically on paper, there is no area [in South Africa] without connectivity’. While recognising that connectivity may sometimes mean climbing a hill to receive a signal – and putting aside the mental image of pregnant women climbing hills to read their pregnancy-related SMS messages – ‘MomConnect will deal with it by hoping that there is a facility to receive a signal and that women may have to try different sim cards and perhaps change their service providers’.

As technology improves and programmes expand, the challenges of addressing place-related health issues change. Increasingly, content is being dispersed to mobile phones throughout Africa, so it is not always possible to link subscribers to particular countries or places. As many SRHR topics – abortion, diverse sexual orientations and gender identity, sex work, adolescent sexuality, condoms – are highly politicised and possibly banned, implementers focus on neutral, uncontentious topics and health-related facts. As one implementer, running an Africa-wide, sexual health social networking forum for young people, commented: ‘What I did as a better-than-nothing solution is I hired an international sexual health advisor to produce information as neutrally as possible’. Yet, implementers still come up against place-related challenges: ‘I wrote a manual about being tested for sexual diseases, but found that the tests were not offered… Place is the biggest missing puzzle piece in our service’.

The problem is political – rural, peri-urban, and inner-city areas are underserviced because of past historical injustice, because the poor live in these areas, because there are no policy prescriptions forcing cell phone operators to provide technology and services to these areas, and because the poor have no purchasing power. Poor women’s and adolescents’ health as experienced in these areas is not eye-catching – gender-based violence, abortion, adolescent rape – and their rights to challenge these experiences are difficult, politically-sensitive topics which do not buy votes. Nor are they easily addressed through the sale of m-health products. The challenge of adolescents’ and women’s SRHRs in rural, peri-urban, and inner-city areas is political. Yet, for many, the solution proposed is often technical.

Picturing gender, ethics and health systems: a competition for photographers

The aim of this competition, organised by Research in Gender and Ethics (RinGs), a new cross-RPC partnership between Future Health Systems, ReBUILD and RESYST, is to capture the everyday stories of the ways that gender plays out within health systems around the world. The winning entry will be exhibited at the Global Symposium on Health Systems Research, and be used to illustrate our website, and in other published materials with full credit to the photographer.

Gender-sensitive health policy is a feature of international commitments and consensus documents and national-level normative statements and implementation guidance in many countries. However, there are gaps in our knowledge about how gender and ethics interface with health systems. Our project shines a light on some of the ways that gender and health systems come together in a variety of settings. We are looking for photographers who can help us communicate this area of work visually. We welcome images of people of all genders from all areas of the health system, all around the world - be creative!

The deadline for entries is the 1 September 2014.

The judging

Photographs will be judged by a panel of gender specialists and a representative from the creative industry. They will be marked according to:

1. Their content, i.e. their relevance to subject.
2. Their ability to tell the story of gender and health systems, i.e. the message they contain, their creativity. We are looking for original and authentic visual representations of health systems in action.
3. The technical merit of the photo, i.e. exposure, focus, colour, lighting etc.

We are looking for images which challenge stereotypes, encourage the viewer to learn more and act differently, and which respect the integrity of any people who may be photographed. There is a rich discussion on the ethics of photography in international development which should help guide entrants. Further information can be found here and here.

Who can enter and how to submit?

Those who have an experience of, or interest in, gender and health systems are very welcome to send images.

Send up to a maximum of three photos by email to RinGs.RPC@gmail.com

Submission requirements

1. Size: At least 1MB
2. Print resolution: 300 dpi
3. Format: JPEG or tiff only
4. Landscape and portrait images are acceptable
5. Although some digital enhancement is acceptable we cannot accept images that have been digitally altered to change what is portrayed.

Send each photo separately and include in your message the following information:

• Name of photographer:
• Photographer email:
• Photographer phone:
• Title of photograph:
• Location (country and city/town/village where the photograph was taken):
• The date (if unknown, please provide the year) each photograph was taken:
• The level of consent provided from any people pictured in the photo (see informed consent guidelines for more information):

Submit your entry

All images should be emailed to RinGs.RPC@gmail.com by the 1 September. We look forward to receiving your entries.

For more details please download the entry requirements and terms. Information about informed consent and a sample consent form are also available.

Sexuality and Sport in Burkina Faso: “Gentle” actions and partnerships that stand up to homophobia

 
Like many sport and development (S&D) organisations throughout Africa, the organisation I have been working with since 2011 in Burkina Faso uses sport to bring youth together and to communicate lessons about HIV and sexual health practice. Using sport as a means of communicating information has shown to be an engaging alternative to talking at young people in a classroom.  As an athlete myself, and one who squirmed through lessons about sexual health in a small room when I was a teenager, I can see the benefit of teaching in a setting where young people are comfortable and attending out of interest, rather than obligation.  

 

Since its inception in 2005, the S&D organisation I work with in Burkina Faso has grown and now works in partnership with the National Ministry of Health, UNHCR, local health organizations and local schools.  Through these partnerships, the organisation has been part of a movement to push policies in Burkina Faso (and West Africa) to extend access to sexual health resources and to fund education about HIV and sexual health in youth centres.[1] Despite the successes of this movement, the drive and focus to educate youth about sexual health has a dangerous blindspot: homophobia and transphobia.

 

The limits of inclusion

I can remember only one occasion during a session about HIV infection out on a football pitch when homosexuality was mentioned.  In this moment, the coach brushed quickly through the mandatory statement that condom use is necessary for protection not only for sex between a man and a women, but also between men. This was followed by giggles.  The coach did not address the reaction of the youth, nor did anyone ask about women who have sex with women, or people who have sex with both men and women. They quickly moved on to the next exercise in the session.  This moment made me pause, and I reflected on how I might feel as a young LGBT person who was part of that group.  I would have felt invisible.

 

S&D programmes that address issues of sexual health should address them for everyone.  These same programmes proclaim inclusion in their mission statements and programme goals; they work with girls, boys, different ethnicities, classes and nationalities, and with youth with disabilities. But how many of them are working with youth who identify as lesbian, gay, bisexual or transgender?  I would venture that the unfortunate answer is that they do not know.  And yet, in a climate where laws in countries like Uganda and Nigeria make it dangerous to even broach the topic of gender identity and sexual orientation, it is understandable that these development programmes may not even know how to begin.  But this is also an opportunity, and an example of a strategic avenue for productive policy engagement that the Sexuality, Poverty and Law Programme at IDS is exploring.

 

The value of ‘gentle’ action

Some of the young women I met through my involvement with sports in Burkina Faso earlier this year introduced me to an organization called the Queer African Youth Networking Center (QAYN).[2] QAYN is based in Ouagadougou and works throughout West Africa.  They are an example of a small group of dedicated young people whose mission it is to support and foster youth activism about LGBT issues and to promote the safety and well being of gays, lesbians, bisexual, transgender and questioning youth in West Africa.  They may not be a very big or visible organization, but they are providing a vital resource to youth who need support.  Just like S&D programmes, they are helping these youth to build confidence and leadership skills. 

 

When I sat with some of the youth who are part of QAYN, and asked them what the biggest problem they face in their community is, the answer they gave me was visibility.  The youth in QAYN work to make LGBT people, and rights, visible; but this visibility also comes at a cost. They told me that they are often shunned by their families, and have to hide from their friends and in public because people just do not have any awareness about diversity of sexual orientation and gender identity.  They said that the more people who know someone who is LGBT and who accepts them, the more their families will begin to understand and accept them. 

 

Some of the youth who have found QAYN take part in the sport activities and sessions on HIV and sexual health that are facilitated by the S&D programme I work with.  In fact, this is how I met them. And yet their identities have been all but invisible in the S&D context.  Is this not an ideal opportunity for a partnership between the S&D sector and an organization that works with LGBT youth to give these young people a voice and critical support?

 

In a conversation with one of the young members of QAYN, he explained that laws – like societal norms – cannot change overnight.  QAYN’s strategy, therefore, uses ‘gentle’[3] actions for building toward change. These ‘gentle actions’ include supporting LGBT youth, creating partnerships with other NGOs in their communities and raising awareness with local organisations and policy makers to lay the groundwork for potential policy and law change in the future. 

 

The members of QAYN are incredibly brave and safety is a perpetual challenge for them, even in a country like Burkina Faso where homosexuality is not specifically outlawed but is socially proscribed[4].  QAYN welcomed me and my colleagues from the S&D organization, offering to help with our sexual health curriculums and activities, and asking with genuine interest if they could visit a sport event.  This rare meeting of sectors is an opportunity to contribute to these “gentle” changes in perceptions that QAYN is working toward, and one that other S&D organisations should actively seek out.   It is part of the necessary on-the-ground steps toward social change that are the undercurrent to legal and policy changes on such controversial issues.

 

By Alison Carney, Consultant and Researcher on Sport, Development and Gender.

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[1] http://www.who.int/reproductivehealth/topics/linkages/RASburkinafaso.pdf

[2] http://www.qayn-center.org/

[3] translated from French: doux/douce

[4] http://www.lgbtnet.dk/countries/africa/burkina-faso

Is the health system response out of sync with the demands of the islanders in the Indian Sundarbans?

Five years ago, a mid-summer nightmare named Aila crashed on the Sundarbans with murderous fury and wreaked destruction beyond repair. On May 25, 2009 the tropical cyclone hit the Sundarbans in India and Bangladesh with a wind speed of 110 km/hr. Over 8,000 people went missing and more than a million were rendered homeless in the two countries. In India about 300 people were killed in Sagar Island alone in the Indian Sundarbans. Figures can scarcely do justice to record the number of homes destroyed, lives lost and livelihoods decimated.

There was a localised health system collapse in the immediate aftermath of Aila – a fact attested by the islanders loudly and by the state health policy makers privately.

Nearness to the state capital Kolkata has been a boon to doctors sent out to the public health facilities in the Sundarbans and a bane to the islanders. Most of the government doctors take it as a day job for four hours and openly flout the government norms. It was -- and still is -- the best known secret in the islands.

The suddenness of Aila left the state health machinery and the 'day doctors' out of reach of the islanders for close to a week. For seven days after Aila, the medical team camped in the landlocked part of the Sundarbans, leaving the islands at the mercy of a few 'braveheart' state doctors and village 'doctors' (or Rural Medical Practitioners, RMPs). Even traversing all the landlocked areas was difficult as the roads were 'sealed off' by the trees uprooted by the cyclone. And this was for the all-weather metal roads. For the rest they were left to their own peril.

When the state could get the doctors to reach their stations they were confronted with overwhelming numbers of water borne diseases that poured into the government as well as the NGO health facilities. Ironically, the health response saw the RMPs and the state doctors working hand-in-hand to tackle the huge case load.

The state health system response, or the lack of it, has taken a toll on the mind space of the islanders who, as the FHS studies would later suggest, have veered more towards the RMPs.

"Nearly 85 per cent of the children of the region could not be taken to the hospital or to a qualified doctor in the event of sickness and were treated by unqualified and untrained Rural Medical Practitioners (RMPs)."

FHS India's How Healthy are the Children of Indian Sundarbans found out – five years after Aila – that nearly 85 per cent of the children of the region could not be taken to the hospital or to a qualified doctor in the event of sickness and were treated by unqualified and untrained Rural Medical Practitioners (RMPs). Aila has irreparably damaged livelihoods – by rendering farmlands unusable, by contaminating fresh water ponds, by drowning families in debt – to such an extent that many villages are now bereft of men. So when a child falls ill, it falls upon the mother or grandmother to take it to the doctor. And it is well-nigh impossible for a woman to carry an ailing child to the block hospital, which may be a several hours by land and boat away from her home.

Hence the dependence on the RMPs, who, though offering care of a dubious quality, invariably have chambers in the heart of the villages, are always available and willing to provide medicines and treatment on credit. Tellingly, a 2010 study by Future Health Systems revealed a significant switch in people's dependence on RMPs vis-à-vis the Aila – about 83 per cent of ailing children in Patharpratima were treated by the RMPs one year after Aila compared to 67 per cent in the pre-Aila year. The How Healthy are the Children of Indian Sundarbans report not only suggests that the absolute dependence on RMPs is a major factor behind the miserable health condition of the children of the Sunderbans but also that the Aila has contributed greatly to this pernicious dependence.
Many of the fields that were abundant before Aila are now barren due to salinity.

The Sundarbans islanders – since the time they have settled down – have been up against two constant disadvantages: a difficult geography and an uncertain climate. Post-Aila, the people had additionally to contend with the uncertainty of the politics born of a regime change. The social and health security schemes are being increasingly marred by politics making the health system of Sundarbans susceptible to any future climate shocks – both big and small.

After the cyclone, five years down the line, as the successive FHS studies reveal, there has been a positive change in the overall health status of the people in the last 10 years. The disturbing peck in this otherwise rosy image is that there has been an increase in climate sensitive diseases like diarrhea and acute respiratory infections (ARI) amongst children. How much of this positive turn in the overall health seeking status can be attributed to the responsive health system and how much it is due to the community's awareness and individual effort to seek care from outside the Sundarbans, though, is a matter of debate and further research.

How indelible is the mark that Aila has left? FHS researchers' interactions with the people, particularly in the course of its study, of the vulnerable groups reveal a different and disturbing picture. Self-reported morbidity of women is significantly on the increase. For the women in the islands, doubly burdened with household chores and stressful livelihood in the absence of their seasonal migrant husbands, the reasons are not hard to imagine. Long periods of wading through waist deep saline water make them more susceptible to vaginal infection and body ache. Mental illness in a phobic situation of uncertain future is now very common in the Sundarbans. Dr. Amitava Chowdhury, the definitive lens which had informed the Amitabh Ghosh's 'Hungry Tide' and who is treating patients for more than 20 years in the islands of the Sundarbans, asserts that the health of islanders is steadily going downhill post Aila: 'I get increasing number of cerebral palsy among children… and also most women seldom weigh more than 40 kg. This, I am sure, is due to lack of nutrition and the general atmosphere of uncertainty and depression post Aila'.

With many of the men having migrated out of the Sundarbans for work, there is a significant burden on local women, who must find safe drinking water, get food, and take care of their own and their family's health. Here a group of women are fishing for their livelihoods.

The situation is compounded by absence of potable water, arsenic contamination and high rate of open defecation in Sundarbans. The availability and acceptability of health schemes have been severely marred by political bias towards selected sections of the population. Political polarisation has complicated the already complex social determinants of accessing health system like physical access, economic access and social access.

In a nutshell, how has the health system responded? If one goes by the WHO guideline of 'a well-functioning health system responds in a balanced way to a population's needs and expectations by: improving the health status of individuals; families and communities defending the population against what threatens its health; protecting people against the financial consequences of ill-health; providing equitable access to people-centered care; making it possible for people to participate in decisions affecting their health and health system' – five years after the fateful Aila equitable access to the health system still remains a distant dream for the majority of the Sundarbans islanders.

By Shibaji Bose, FHS India Policy Influence and Research Uptake Officer

Time for new approach to health systems in developing countries, parliamentary meeting told

The All Party Parliamentary Group (APPG) for Trade Out of Poverty, the APPG for Debt, Aid and Trade and IDS co-hosted a meeting in parliament examining how governments, businesses, practitioners and academics can collaborate more effectively to ensure that health markets in developing countries work better for the world's poorest communities.

Chaired by Lord Crisp, it was the first in a series of meetings being organised by the three organisations entitled Driving private sector for public good which will look at how UK development policy needs to evolve to ensure the beneficial long-term impact of business and development initiatives on the well-being of the poorest communities.

Current thinking on health systems and markets out of date

In his opening comments to the meeting, IDS Research Fellow Gerry Bloom highlighted that compared to 30 years ago when the major guiding frameworks for international health policy were agreed, people in poorer countries have much better access to drugs, health workers and information about health services. Access has improved as a result of the rapid developed of mixed health systems, which incorporate both public and private providers (either formal or informal). However, understanding of these systems and markets has not kept pace with the changes that have taken place and new strategies and approaches are now urgently required if performance is to be improved.
Referring to his work as part of the Future Health Systems consortium with partners in the US, China, India, Bangladesh, Afghanistan, Nigeria and Uganda, Dr Bloom argued that more needs to be done to share learning and best practice across countries and between governments, businesses, practitioners and academics. He underlined the potential of informal markets in developing countries to broaden access to health care and services. However he was also clear that improved regulation of these markets was needed to ensure the quality, safety and appropriate use of drugs and to address issues such as the over-prescription and use of antibiotics which was leading to growing resistance to these drugs.

Health innovations in Bangladesh and the challenge of scale and sustainability

Drawing on examples from Bangladesh and a scoping study of health innovations that he undertook in conjunction with IDS, Rubaiyath Sarwar, Managing Director of Innovision, also highlighted a number of opportunities in relation to expanding informal health markets and private sector providers. He referred to a number of innovative approaches that were being implemented in Bangladesh including floating hospitals and the Mobile Alliance for Maternal Action which provides health information to new and expectant mothers via their mobile phones.

However Rubaiyath Sarwar also raised two important challenges in relation to these innovative approaches. How can they be made sustainable, particularly in terms of ongoing financing, and how can they be taken to scale? Addressing these questions is critical to progress and improvements.

Private sector investment in health in poorer countries

Another challenge that was highlighted by Dr Allan Pamba, Vice President, Pharmaceuticals, East Africa and Government Affairs, Africa, GlaxoSmithKline (GSK), was in relation to the risk attached to, and potential lack of incentives, for private companies and businesses to invest in health systems in poorer countries. He used the example of Africa, which has only 1% of the global health budget and 3% of the global health workforce.

However Dr Pamba highlighted that companies like GSK have taken a broader perspective that not only demonstrates value to shareholders but also has significant social impact in developing countries. In order to achieve this, he explained how GSK has had to adapt their business models to work in some of the least developed countries and partner with NGOs and governments to reach the poorest communities, which he admitted still presented a real challenge.

Ensuring health services and markets are targeted at the hardest to reach

Ensuring access to health care and services for the hardest to reach was also an issue that Patricia Atkinson, Vice President and Health Systems Director at Marie Stopes International highlighted in her contribution to the discussion. She spoke about how Marie Stopes was working with partners to increase the utilisation of health services and exploring how health insurance schemes in countries such as Ghana and Kenya could be targeted at the poorest 20% of the population.

Listen to the speakers' presentations

Strengthening health markets for universal coverage by Ids (Uk) on Mixcloud

By Hannah Corbett, IDS Public Affairs Officer

Global health meets genomics: inequality and politics

Photo: H1N1 top view by oschene on Flickr (cc-by-nc-sa)

Scientific advances in the understanding of genetics and genomics have the potential to generate major improvements for human health in the near future. However, from a global health perspective, the translation of this technology into new medical treatments raises profound international and local issues around inequality, identity and insecurity.

 

On 18th July 2014, we attended an interdisciplinary one-day conference at the University of Sussex which brought together experts from various fields to examine the complexities around the issues of genetics, genomics and global health.

Keynote speaker Andrew Lakoff, Associate Professor of Anthropology, Sociology and Communication at the University of Southern California, presented a provocative juxtaposition between the new techniques of molecular biology (genetics and genomics) and global health: the world of genomics is currently largely geared towards the aging population of the wealthy world, whereas global health focuses on the developing world, is underfunded and under the purview of development agencies.

Lakoff presented what he described as two normative regimes within global health:
• Humanitarian biomedicine, which focuses on treating existing diseases afflicting populations in the developing world.
• Global health security, which prepares for the onset of potential future diseases that might afflict members of the advanced industrial world.

Ebola, humanitarianism and security

This week we have seen both regimes at play in the publicity and action around the unfolding Ebola crisis in West Africa. While governments and NGOs struggle to contain a devastating humanitarian disaster destroying lives and communities in Sierra Leone, Liberia and Guinea, British and North American policymakers and media highlight the security risks to their populations of the outbreak 'going global'.

The ironies and politics between these competing narratives around outbreaks and epidemics are highlighted in IDS work on Ebola, including in a recent IDS feature and in a blog for the Bulletin of the WHO, Time to put Ebola in Context.

Lakoff considered issues around genetics and genomics through the lens of these two regimes, showing how they raise ethical, political and economic challenges. First, the issue of viral sovereignty was raised during the avian flu (H5N1) crisis, when Indonesia refused to share genetic samples of the virus with the WHO based on grounds of equity for low- and middle-income countries. This action divided the global health arena – to some, it was undermining global health efforts and putting lives at risk; to others, it was a demonstration of a need for more transparent, equitable and fair virus sharing. As a result, the new WHO Pandemic Influenza Preparedness framework has acknowledged the principle of sovereignty.

A second example is the uncovering of hidden ties between global health agencies and pharmaceutical corporations, consisting of contractual agreements to secure national stocks of vaccines in preparation for the swine flu (H1N1 influenza) outbreak. Many developed countries ended up with a surfeit of medicines for H1N1 (e.g. the US only used half of their vaccine stock), and consequently tried to offload their surplus to developing countries. This case highlights that whilst spending on pandemic scenarios continues, often despite a weak evidence base, only lip service is paid to the great killers currently affecting global health.

As Lakoff argued, these cases indicate that harnessing scientific advances to address issues of global health involves challenges that are political and ethical, as much as technical. They also highlight the significance of inequalities in the intersections between genetics, genomics and global health.

Can the 'genomics revolution' tackle inequality?

These were the focus of a panel session that we chaired, 'Closing the Gap in Health Inequalities – is Genomics Part of the Solution?'. Here, presentations from Audrey Duncanson of the Wellcome Trust, Michael Hopkins of SPRU, and Stuart Hogarth of Kings College London animated a lively debate.
From some angles, a 'genomics revolution' promises major benefits in the prevention, diagnosis and management of non-communicable diseases that have been hard to control, offering a new generation of personalised medicine, new tools and therapies. Some argue that there is great potential for their application in the developing world including Africa, as these diseases rise in significance relative to longstanding killers such as diarrhoea and pneumonia. Efforts to build genomics science and science capacity in Africa and other low income settings, attuned to their particular problems and genetic variants, are therefore urgently needed.

Yet an opposing perspective suggests that even in high income settings, genomic medicine has not lived up to its hype. It has yielded relatively few new therapies, while the big wins in treating non-communicable disease have generally come from established therapies applied in new ways, along with tried and tested public health approaches – such as the use of aspirin, statins and smoking cessation in dealing with cardio-vascular disorders. Genetic testing and molecular diagnostics may offer the biggest potential health wins, but high costs – supported by the business models and intellectual property regimes of the pharmaceutical industry – limit their use even in the Global North. For developing countries, they are usually prohibitive.

As a lively debate emphasised, currently genetic and genomic medicine is big on science, and promise, but small in impact. Translating science into workable technologies requires institutions and infrastructures, and these are often missing. As an expensive technology, benefits in terms of health outcomes are confined to a few.

Perspective needed

In this context, genomics is probably not increasing health inequalities as some have feared; its impact is not great enough for that. But it is not closing the gap either. Cheaper, more appropriate therapies and diagnostics might in the future bring health benefits to low income populations in Africa and beyond. But it is important not to let these directions of innovation – and the regimes, narratives and pathways that form around them – distract from others.

Applying old, established technologies more widely through strengthened health systems and markets, public health measures such as improved sanitation and water supplies, and tackling broader socio-economic and political disparities, ultimately offer stronger prospects for reducing global health inequalities – and for meeting global health agendas driven by humanitarian as well as security concerns.

For more on Ebola and other animal-to-human diseases, see our zoonoses hot topic.

This post was written by Melissa Leach, Director at the Institute of Development Studies, Gemma Buckland-Merrett, Research Fellow at the University of Sussex Centre for Global Health Policy, and Leah Murphy, Eldis Global Health Editor. It was first published on the Eldis website.

Ebola: failures, flashpoints and focus

As the worst Ebola epidemic on record shows no signs of abating in West Africa, fear and ignorance are increasingly said to be playing a role in its continued spread. Meanwhile, local practices such as the consumption of bushmeat and deforestation are the go-to explanations for the epidemic's underlying causes. However, decades of anthropological research in the region by STEPS Centre and Institute of Development Studies (IDS) researchers, indicates not only that this picture is an over-simplification, but that disease control policies based on these ideas may be unhelpful.

The latest news from West Africa is troubling: outreach and surveillance officers have been attacked, rumours circulate that the disease does not exist, that medical staff are harvesting organs and anyone going to hospital will not come out alive. Tear gas was reportedly used to disperse a crowd at Sierra Leone’s Kenema Government Hospital who were demanding the release of family members admitted to the Ebola treatment centre there. As many as 57 patients are reported "missing" in the country, either fleeing treatment centres or avoiding them altogether. This seriously hinders contact tracing and infection control efforts.

Both the Sierra Leonean and Liberian presidents have said anyone obstructing suspected Ebola patients from receiving official treatment will be punished. But these announcements are unlikely to have much effect, being disengaged from the reasons behind the community suspicion and the complexities of the socio-cultural context.

An important lesson from early outbreaks in Central Africa was to include anthropologists in the response teams so that local knowledge could be used to strengthen control measures and minimise fear. Medecins Sans Frontieres (MSF) have been using anthropologists as part of their team in this current episode too, but the rumours are proving hard to beat. IDS Director and STEPS Centre former Director Professor Melissa Leach, has lived and worked in the region. MSF recently asked for her anthropological insights, so we at IDS and the STEPS Centre have been thinking about how to put the disease and responses to it in context.

Disease and health seeking
Even the most remote rural populations should not be assumed to be unfamiliar with concepts of modern medicine, however their engagement with them may be mediated by other logics. People are accepting of Western medicine but are ambivalent about the formal health system. The history of Lassa fever, another viral haemorrhagic disease which has been recognised as endemic in the area for decades, is relevant. During my doctoral research on Lassa fever I was told of longstanding rumours about medical staff administering lethal injections. Patients have been known to avoid the Lassa ward in Kenema.

Underlying health seeking patterns, is the fact that people hold multiple models for interpreting and responding to sickness. In Mende areas, there are general categories of big and small fever, and ordinary and hospital sick, as well as specific biomedical diseases. Lassa was classified a 'big fever' and Ebola may well be too. Diseases can be understood as caused by multiple things, including germ theory or 'witchcraft'. These causes are not necessarily mutually exclusive. A diagnostic test which 'proves' someone has an illness may not be viewed as conclusive. Key to understanding health seeking is to understand how disease categories shift as the illness progresses. The way people and those around them have behaved, the events leading up to the illness and circumstances surrounding its onset all influence the model which is applied and the treatment sought.

Death and 'secret' knowledge
Traditional burial practices have been implicated in transmission as they involve mourners having contact with the deceased infectious body. The importance of burial practices cannot be underestimated as they are strictly controlled by the male and female societies (known as 'secret societies' in English) who are central to local and regional politics. Medical teams wishing to prevent traditional burials will likely be intervening in domains of power and 'secret' knowledge that lie at the heart of the socio-political fabric which society officials control.

Secret knowledge, and membership of particular societies which offer access to that knowledge (to different degrees) characterises this region of West Africa. Much about the medical response may resonate with these themes: hiding patients behind screens (in isolation), wearing masks (protective clothing). It may be that medical teams are interpreted as another 'secret society'. Response teams should be sensitive to these possibilities and aware of why they may face resistance.

As with disease, there are multiple kinds and causes of death. Certain circumstances – such as sudden death or that of a pregnant woman – raise suspicion. 'Witchcraft' is the most frequently discussed but this confuses some distinct phenomena including malicious spirits, bad intent by sorcerers, and inappropriate behaviour. Such deaths may require special practices and again secret knowledge is likely to be important. This may be an additional reason why funerals are proving a flashpoint in this epidemic. It is possible that by not allowing the secret societies to carry out the appropriate cleansing after unusual deaths that medical teams are perceived to be making the situation worse.

Avoiding simple explanations: the need for a social science
While the recognition of Ebola in the area is new, people are likely to be interpreting and responding to it in line with longstanding local frameworks. Public behaviours and attitudes that might at first sight appear to reflect ignorance, can and should be seen as part of cultural logics that make sense given regional history, social institutions and experience.

Viewing conflicts as stemming from opposing categories of traditional and modern does not capture the complex and emergent meanings which define life in this region and this epidemic. This blog highlights only a small part of this, but it illustrates the need for a social science perspective. That perspective should also include examining the politics of knowledge which are at play. Simple narratives that blame the epidemic on local people for eating bushmeat and deforestation are already appearing. Prof. Leach has highlighted how these overlook well established patterns of land use and interaction with bat habits and so are unlikely to explain why the disease has emerged in West Africa now.

It is hard to say much with great certainty about Ebola, except that it is terrifying and tragic for those affected; all the more need for researchers, health workers, policy makers and the media to be cognisant of the power and politics involved in responding to and controlling the disease.

By Annie Wilkinson, post doctorate researcher, Institute of Development Studies

Find out more:

• Hot Topic: Zoonoses and the truth about Ebola
• Ebola in Guinea – people, patterns and puzzles Melissa Leach, Lancet Global Health blog
• Tackling the Ebola epidemic in west Africa: why we need a holistic approach Naomi Marks, The Guardian
• Haemorrhagic Fevers in Africa: Narratives, Politics and Pathways of Disease and Response STEPS Working Paper by Melissa Leach
• The book Epidemics: Science, Governance and Social Justice includes a chapter on Ebola and Lassa fever.
• Dynamic Drivers of Disease in Africa Consortium

Antibiotics: avoiding a return to the dark ages of medicine

Sean Warren, iStockphoto

Listeners to BBC Radio 4’s Today programme woke up yesterday to Prime Minister David Cameron’s prediction of a return to the “dark ages of medicine” if the problem of growing antibiotic resistance is left unchecked.

This doomsday scenario is one where routine infections which we have come to think of as treatable nuisances, are once again life threatening; where modern medical procedures such as cancer treatment and surgery, threaten patient’s lives by leaving them vulnerable to untreatable infections instead of extending and improving lives. This is scary stuff. And scarier still is the fact that most agree it is not scaremongering. Indeed, it is already happening. The European Centre for Disease Prevention and Control looked at five well known antibiotic resistant bacteria and estimated that they alone caused 25,000 deaths a year in Europe.

Today Mr Cameron announced an independent review into how to tackle the global resistance problem; as penicillin was a British invention, it was fitting, he said, that Britain should now provide leadership. He defined the challenge as consisting of three elements: evolving resistance, the lack of development of new antibiotics and the over use of existing antibiotics.

The first is an unavoidable process, due to natural selection, which can be influenced but not stopped. On this, the focus on drugs should not detract from the importance of sanitation and infection control; one way to influence the development of resistance is to influence the rate of infection. Worryingly, there are currently huge gaps in what we know about the levels of resistance around the world.

The second element is tricky too. The golden age of drug production is long gone and getting effective drugs to market is expensive and uncertain. Pharmaceutical companies argue that they face limited returns on their investment as not only are antibiotics poor money-spinners (being short-course and low cost treatments), but it is likely that sales of new drugs will be restricted as governments try to regulate their use more strictly. Still, new business models for research and development are plausible and already being negotiated.

The third element, drug use, is potentially the most complex and challenging of all. Inappropriate drug use is a problem the world over and key will be finding ways to regulate the consumption of medicine. Any British leadership on this issue must consider that, in contrast to the highly regulated NHS or European health system models, people in many Low and Middle Income Countries (LMICs) access healthcare through disorganised and unregulated markets, with the poor in particular relying on informal providers.

In these markets the use of antibiotics is rife, with the World Health Organisation (WHO) reporting they account for 40- 50% of prescriptions. Stopping ‘irrational’ and ‘inappropriate’ use of antibiotics is a common refrain. Yet these labels detract from the many risks and uncertainties which people and healthcare providers weigh up when deciding on treatment, often in the absence of diagnostics. Faced with high and dangerous disease burdens, and with limited access to good quality health services and products, using these medicines presumptively is understandable, and at times beneficial. Indeed it was not long ago that the WHO was recommending presumptive treatment of malaria in endemic regions.

The crux of the issue is the access/excess balance. How can you regulate in a way which ensures essential medicines are available when needed, but are not overused so that they become ineffective? This also involves a trade off between individual and societal needs. The availability of cheap generic drugs to hard to reach populations through informal channels has undoubtedly reduced morbidity. It has been suggested that the impressive reductions in child and maternal mortality in Bangladesh can be attributed to increased access to antibiotics to fight infections. Top down responses such as tightly restricting the availability of antibiotics, to only formal providers for instance (if that was even possible), may adversely affect the poor and vulnerable who face barriers accessing such services. As such they may also work against key development goals like reducing maternal mortality or achieving universal health coverage.

Work by colleagues in the STEPS Centre has highlighted the ways in which regulation must be appropriate for local realities. The informal sector is both problematic and potentially a life line. Attempts to ensure access and also limit antibiotic resistance must take the significant role they play in health systems into account. At the Institute of Development Studies we are partnering with organisations in LMICs who have longstanding relationships with these informal health providers in order to understand the local contexts of drug use more fully.

By Annie Wilkinson, post doctorate researcher, IDS

MakSPH joins hands with Uganda’s Health ministry to hold symposium on teenage pregnancy

By Kakaire Ayub Kirunda, MakSPH

When the Future Health Systems team at the Makerere University School of Public Health (MakSPH) approached Uganda’s Ministry of Health, with an idea of a symposium as part of the activities to commemorate the safe motherhood month held every year in October, it was not clear what to expect.

But bingo, the idea was taken on board, seeing the United Nations Population Fund, the World Health Organisation, and Marie Stopes Uganda become co sponsors with MakSPH for the event now being planned to be held annually.

Organised under the theme “Teenage Pregnancy: An Obstacle to Maternal Health, Let’s Stop It Now,” the 2013 inaugural symposium held on November 5 drew the attention of teenage mothers, the academia, policy makers, religious and cultural leaders, legal practitioners, and the media among other stakeholders.

In a speech read for him at the symposium, Uganda’s State Minister for Health Dr Elioda Tumwesigye said there was urgent need for investment in the sexual and reproductive health and rights of young people in order to address the underlying factors that give rise to the high rate of teenage pregnancies.

“Although some of the laws and policies in Uganda address this issue of teenage pregnancy some of our laws still have loop holes which promote teenage pregnancy,” said Dr Tumwesigye. “Similarly although the Uganda Ministry of health supports the provision of adolescent friendly services, its provision has been met with some challenges.”

Teenage pregnancy in Uganda is compounded by adolescent girls’ vulnerability to early and sometimes forced marriage, with the country having one of the highest child marriage prevalence rates in the world.

According to the latest Uganda Demographic and Health Survey, among women age 20-49, 15 percent were married by age 15, and 49 percent were married by age 18.

The UNFPA Country Representative for Uganda Ms Cecile Compaore applauded efforts by the symposium organizing partners for efforts aimed at discussing how to strengthen efforts to fight teenage pregnancy using a multi-sectoral approach, saying breaking the cycle of teenage pregnancy required action from all sectors working together and not just the health sector.

She added that the more harmonised the efforts, the better the service delivered to the girls and women of Uganda and interventions help the most vulnerable, especially girls between 10 and 18, who need support that builds their potential and protects their rights.

Also speaking at the symposium, MakSPH Deputy Dean Prof. Christopher Garimoi Orach urged stakeholders to follow up on the recommendations and commitments made by the various stakeholders in relation to mitigating teenage pregnancy in the country.

“We have to put our hands together and this calls for us meeting frequently,” he urged the participants.

The various stakeholders who attended the symposium made recommendations and commitments to be followed up over the following year.

From the religious and cultural leaders, among the many recommendations made was one on the need for networking with other stakeholders especially researchers on the need to come up with practical ways of tackling the spiraling problem of teenage pregnancy.

The legal and ethical issues stakeholders comprising mainly of lawyers pledged to spearhead a campaign on awareness especially on laws relating to children.

Among other things, the academia called for studies to look into the cost effectiveness of the current interventions that are aimed at preventing teenage pregnancy. They also called for studying the best model for parent to child communication to prevent teen pregnancies.

Young people, specifically teenage mothers who attended at the symposium asked Government to inject funds in programs to train personnel to impart positive skills like self-esteem and confidence among girls to say “NO”.

Meanwhile the symposium featured an exhibition of photographs from an FHS funded study at MakSPH that looked at the use of photo voice to involve the youth in identifying maternal health issues in the community and in identifying opportunities to engage in their improvement.

 

According to the study’s principle investigator Mr. David Musoke, “A lot of interest was shown particularly in the research methodology of using photos, some thinking of incorporating it into their work. The booklet was also very handy as many participants took with them copies.”

“AIDS has a woman’s face”, or does it? Beyond the Gender and HIV Dyad

By Elizabeth Mllls, KNOTS fellow

As we approach World AIDS Day, and move into 16 days of activism against gender-based violence, I am prompted again, to reflect on some of the important links between gender-based violence and HIV, and also some of the problematic assumptions that perpetuate uncritical thinking on the gender-HIV dyad.

A Discomfort with Development Categories

Meet Zama, a 33-year old South African woman and an old friend of mine; she has been an AIDS activist and professional HIV treatment literacy practitioner in South Africa since the height of AIDS denial in the early 2000s.  Zama lives in Khayelitsha, which means ‘new home’ in isiXhosa. Its name is rather cynical, given that in this area homes are rarely ever permanently sunk into the earth. Space matters here when the only source of water is a leaky tap, whose muddy veins run down unlit side alleys where women risk rape when they leave their homes at night, or when all adults and children risk electrocution (from illegal wires that wind through the sand) when walking to the single toilet that also serves their 500 – 1000 closest neighbours. Khayelitsha is also the space where women have stood with men, in conjunction with the Treatment Action Campaign and Médecins Sans Frontières, to call on the state to provide essential AIDS medicines; it is the place where these medicines were first made available through the MSF trial in 2001.

Like almost 33% of Khayelitsha’s residents, Zama is also HIV-positive; and like almost two million South Africans, she is on ARVs. She explains,

“It’s like when the skies fight, when the clouds are angry and dark. They crash into each other and lightning flies across the sky. You never know where the lightning is going to hit. That’s what it’s like with HIV” (Zama, 2011).

In this conversation, Zama told me how she had initially found it difficult to negotiate safe sex, or sex at all, when she was a young woman. Zama had been wary of narrating this ‘illness history’ because it colluded with the ‘development category’ of the poor, black HIV-positive woman who was unable to actively navigate her own life. In fact, she eschewed labels like ‘HIV-positive woman’ and considered herself to have substantial personal power to negotiate her current sexual, socio-economic and political relationships.

Looking beyond Victimhood: Between Agency and Structure

While the presence of gender inequality, and its brutal manifestation as sexual violence in girls’ and women’s lives, is a strong feature of my work, I – like Zama – have been confronted by the explanatory limitations of epidemiological assertions that stipulated a correlation between gender inequality and higher rates of HIV infection among women compared to men. I do not dispute this correlation; my research has been informed by the multiple and intersecting inequalities that seemed to drive HIV, in epidemiological terms, into women’s lives and bodies. This was most striking when, in 2008, young women in South Africa were almost four times as likely to be HIV-positive compared to young men of the same age (20 – 24) (Johnson et al., 2013, Dorrington et al., 2006).  Overall prevalence in this age group has subsequently declined, but the characteristics of prevalence according to sex remained the same: young women are still more likely to be HIV-positive than men (UNAIDS, 2012).

Studies link these statistics to sexual violence. Articles with titles like “AIDS has a woman’s face” or “Troubling the angels” proliferated in research that explored this correlation.  Other research suggested that sexual violence and its relationship to HIV occurs against an inflected backdrop of pervasive and entangled inequalities in South Africa, where gender, sexuality, race and class powerfully intersect to reinforce poor Black women’s vulnerability (Dworkin et al., 2012, Jewkes and Morrell, 2012).

Although these studies give texture to the correlation between gender inequality and high rates of HIV incidence among women compared to men, they may also (unwittingly) support a paradigm that has fuelled development interventions to ‘empower’ women by foregrounding women’s relative lack of power compared to men. Ascribing HIV transmission, in epidemiological terms, to entrenched gender inequality does not, in itself, engage with the complex pathways that women navigate between desire and risk in their sexual relationships, and in extremely difficult socio-economic contexts.  In this respect, my research shows that women are subtly, and sometimes with great difficulty, negotiating their intimate relationships with men by forming separate households and by working and establishing their financial independence. This was not a straightforward matter of asserting agency or submitting to intersecting structures of inequality.

The Biopolitics of Violence: Bringing a Global Network of Actors into View

In my research on gender and HIV, and now as I convene the Sexuality, Poverty and Law Programme at the Institute of Development Studies, I suggest that we – researchers, policy makers, activists – need to be careful about situating vulnerability in individual bodies and relationships. I propose that we nuance our analyses to look at how people’s bodies and lives are located in a far more complex network of actors. I suggest, then, that the gender-HIV dyad is problematic not only because it positions women as passive victims of men who are, conversely, held to be active perpetrators (or even more unhelpfully, ‘vectors of transmission’). More fundamentally, it is problematic because these discourses direct our attention towards individuals or ‘cultures of inequality’ and away from the biopolitics of violence in which national, regional and global actors are implicated.

While we certainly need to address the manifestation of inequality in people’s lives, the bolts of lightening, we also need to explore the context – the skies that fight – in which women’s lives are located. This includes a recognition: of the subtle ways that women hold agency, albeit fraught and contested; that men are a part of the solution in working towards equality; and that national, regional and global actors need to be held to account for the ways they intimately affect our lives, from a distance, at the most molecular level.

References:
Dorrington, R., Johnson, L., Bradshaw, D. & Daniel, T. (2006) The demographic impact of HIV/AIDS in South Africa: National and provincial indicators for 2006. Cape Town.

Dworkin, S. L., Colvin, C., Hatcher, A. & Peacock, D. (2012) Men’s Perceptions of Women’s Rights and Changing Gender Relations in South Africa Lessons for Working With Men and Boys in HIV and Antiviolence Programs. Gender & Society, 26, 97-120.

Jewkes, R. & Morrell, R. (2012) Sexuality and the limits of agency among South African teenage women: Theorising femininities and their connections to HIV risk practises. Social Science & Medicine, 74, 1729-1737.

Johnson, L. F., Mossong, J., Dorrington, R. E., Schomaker, M., Hoffmann, C. J., Keiser, O., Fox, M. P., Wood, R., Prozesky, H. & Giddy, J. (2013) Life Expectancies of South African Adults Starting Antiretroviral Treatment: Collaborative Analysis of Cohort Studies. PLoS medicine, 10, e1001418.

UNAIDS (2012) World AIDS Day Report - Results 2012. UNAIDS.

Health in a changing climate

Source: Jessly Obando

by Fatema Rajabali

I am currently in Warsaw, Poland for the United Nations Climate Change Conference (COP19). On 16 November, I attended the Climate and Health Summit, which was organised by the Global Climate and Health Alliance (GCHA). I was particularly interested in this event as I have a narrow understanding of the complex climate change and health interconnections, especially around issues of mental health and well being.

With the tragic events of Typhoon Haiyan in the Philippines so recent, I wondered how other vulnerable countries, with less social welfare and support programmes in place, would meet development goals after such calamities. There is enough to deal with when you have lost loved ones, your community, home and all your basic possessions. And when people are displaced, there are so many other complex issues that come into play. For instance, as Liz Hannah from the Australia National University highlighted: ’there are an increase in rapes and sexual assaults among displaced communities.’

Building of collective momentum among the health community

At the summit, multiple presenters argued that climate change is a health issue and the sector should not be shy about participating in this dialogue. Even though the Copenhagen Accord only mentions health once, there are hopeful signs, which Diarmid Campbell-Lendrum from the World Health Organisation outlined as:

• The public identifies with the correlation between health and climate change.
• The World Health Assembly has a resolution to act on climate change.
• There are expanding programmes on health adaptation although there is now a need to try institutionalise programmes.
• There are new initiatives supporting climate change mitigation. This includes decreasing air pollution and its effects.

But the health community needs to be working at a larger scale, learning and leveraging from initiatives that have had major successes in the sector. This includes the public health action from the tobacco industry as well as the campaigns and work on HIV/AIDS programmes. The health sector is not poor, as one of the participants noted, but how do we make sure that money is being funnelled into these programmes?

Links between nutrition, health and climate change

What we put into our bodies is also a significantly important part of the discussion. Christina Tiraldo, a Professor at the School of Public Health at UCLA provided an interesting insight into some of the key links and challenges in building synergies in the nutrition and health sectors in a changing climate, especially as we work towards a Rio+20 world. She noted that Climate Smart Agriculture needs to have a nutritional component.

 

If not us, who: If not now, when?

And while the health sector engages in this debate, the youth of today, represented by the International Federation on Medical Students Associations (IFMSA) emphasised their need to be engaged in this process. Building the capacity of medical students across the globe so that they can develop the confidence and skills to lead in this dialogue sounds like a worthy investment. After all, as Charlotte Holm-Hansen from IFMSA noted: ’this is not just a role for middle aged white men to be playing’.

Following COP19?
If you’re interested in staying up to date with the latest research and commentary from COP19, with a focus on looking beyond the Millennium Development Goals, please follow our virtual narrative via Storify

Are there things we aren’t covering sufficiently? Let us know what you think:
f.rajabali@ids.ac.uk  / a.hall@ids.ac.uk

If you’re looking for more cutting edge research on the interlinks between health, nutrition and climate change:
http://eldis.org/go/topics/resource-guides/climate-change

First Sundarbans Health Watch asks 'How healthy are the children of the Indian Sundarbans?'

Professors Barun Kanjilal and Rabindranath Bhattacharya
present a copy of the Sundarbans Health Watch - Series 1

KOLKATA, INDIA - On 1 August 2013, researchers, practitioners, policy makers and media represnetatives gathered to gain a better understanding of the key trends in child health in the Sundarbans region of West Bengal, India. In addition to presenting findings from the first Sundarbans Health Watch, various local and international NGOs -- such as Terre des Hommes, Child in Need, CRY, Save the Children and the Riddhi Foundation -- discussed their current activities in the region.The introductory address by FHS India leader, Professor Barun Kanjilal of IIHMR, presented the Sundarbans Health Watch, which asks 'how healthy are the children of the Indian Sundarbans?'. The study is based on intensive surveys conducted in the Patharpratima Block of the Sunderbans and throws light on some alarming – and largely ignored – facts about the health status of the children of the Sundarbans. It also attempts to explore the 'structural holes' in the service delivery of public health care system and the role of informal providers in filling the gaps.

While the vigorous reproductive and child health care initiatives of the state have been able to protect the rights of children and their mothers to obtain preventive health care (such as, immunisations, ante-natal care, etc.), there are glaring gaps in addressing their rights to easily access quality-assured basic curative care and nutritional services. Repeated climatic shocks and geographical adversities, especially in the remote islands, add to the complexities and make it imperative for the local policy actors to adopt a special child-focused lens to fill in the gaps and reach the hard-to-reach children.

Key findings (which can also be viewed as an infographic) of the study include:

• More than one-third of the children are chronically malnourished. More than one-third of the mothers are also malnourished.
• Children of the Sundarbans face an extra burden of morbidity, with data suggesting that 0.3 million children will be ill in a month and 26,000 children will need hospitalisation in one year in the Sundarbans.
• Prevalence of respiratory infection or gastrointestinal disorders among children is much higher in the Sundarbans than the district or state average.
• A quarter of the children (of surveyed households) aged 0-12 months took birth and spent the first week of their lives without any medical supervision from any health worker.
• The available public health care system is grossly inadequate to maintain child health. Primary Health Centres (PHCs) are not only less available, but many of them run ineffectively with shortage of critical inputs.
• Given the failure of the public health care system to cater to child health care needs, a parallel market has cropped up to bridge the huge gap in the curative care market. Unqualified RMPs dominate this parallel market, which is, obviously, a potential threat to child health. But this scenario also offers an opportunity for the government to challenges these sector through training and other innovative strategies.
• 85 per cent of the outpatient treatment for ailing children is provided by the Rural Medical Practitioners (RMPs) of questionable quality.
• There are many NGO initiatives but too few focusing on child health.

Following the report launch, Terres des Hommes presented on their efforts to combat child malnutrition in disaster prone blocks and convergence with state led Integrated Child Development Services. The Child in Need Institute, a national level implementation NGO, also put forth their initiatives for addressing malnutrition. CRY argued for a child rights approach in addressing child health, while Save the Children called for linking up livelihood and health initiatives especially in climatically challenged zones. The Riddhi Foundation called for an effective and judicious usage of information and communication technologies (ICTs) both in ascertaining the demand and supply of health services in disadvantaged regions for betterment of child health.
Based on these presentations, the former Additional Chief Secretary, M. N Roy, called for close collaboration of the panchayat and the health system for effective delivery of the health services to the children of the poor families in the Sundarbans islands. Additionally, Dr Abhijeet Choudhur, the founder of the Kolkata chapter of Liver Foundation, called for training of the rural medical practitioners (RMPs).

Participants in the meeting agreed that, to improve the lives of children in the Sundarbans, a series of initiatives engaging all types of service providers and innovatively putting pieces of interventions together was required. These initiatives need to come together to create a big push and reach a sustainable, equitable and high level of delivery system. Participants insisted that the time has come to acknowledge the uniqueness of the health care needs of the complex, climatically vulnerable, topographically challenged and economically underperforming region called the Sundarbans and focus on them with special attention.

There have been numerous media reports of the event. The Hindu, for example, notes that 'Sunderbans children highly susceptible to diseases, says study'. And several news organisations, including the Business Standard, carried the story 'Climate change affecting health in Sundarbans'.

Originally posted on the Future Health Systems blog